Karen Feuerman, Ph.D.
Assistant Professor, Albizu University
kfeuerman@albizu.edu
Jessica J. Ruiz, Psy.D.
Assistant Professor, Albizu University
jruiz@albizu.edu
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 Be
able to accurately define transgender
 Differentiate
between transgender and
gender dysphoria
 Identify
substance abuse treatment needs
within the transgender population
Biological Sex
Gender Expression
Sexual Orientation
Female
Feminine
Male
Male
Masculine
Female
Sex- “Biological indicators of male and female…such as sex
chromosomes, gonads, sex hormones, and nonambiguous
internal and external genitalia” (APA, 2013 p. 451).
Gender – The psychological, biological or cultural
characteristics associated with maleness and femaleness
(Kessler & McKenna, 1978; Ruble, Martin, & Berenbaum,
2006).
Gender Identity-Refers to a person’s basic sense of being
male, female, or of indeterminate sex (Stoller, 1968).
Gender Role- Gender role refers to behaviors, attitudes, and
personality traits that a society, in a given historical period,
designates as masculine or feminine-that is more typical of
the male or female social role (Ruble et al., 2006).
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Refers to the way in which a person acts to communicate gender within
a given culture; for example, in terms of clothing, communication
patterns, and interests.
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A person’s gender expression may or may not be consistent with socially
prescribed gender roles, and may or may not reflect his or her gender
identity
(APA Task Force on Gender Identity and Gender Variance, 2009)
LGBT
Lesbian
Gay
Bisexual
Sexual Orientation
Transgender – Gender Identity
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Transgender- or gender variant refers to the behavior,
appearance, or identity of persons who cross, transcend, or
do not conform to culturally defined norms for persons of
their biological sex (APA Task Force on Gender Identity and
Gender Variance, 2009)
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Transgender - An umbrella term used to encompass any
self-expression or identity that does not conform to a binary
concept of female and male (YES Institute, 2015).
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https://www.youtube.com/watch?v=MsVu8my2wRY
DSM IV-TR - Gender Identity Disorder
DSM 5- Gender Dysphoria
Marked incongruence between one’s
experienced/expressed gender and assigned gender of
at least 6 month duration
Children- Need at least 6 symptoms
Adolescents and Adults- Manifests at least 2
Condition is associated with clinically significant distress or
impairment in social, school, or other important functioning
APA, 2013
Children
 Desire to be of the other gender or insistence that one is of
the other gender
 A strong preference for toys, games or activities
stereotypically used or engaged in by the opposite gender
 A strong rejection of typically masculine toys (in boys) and of
feminine toys (girls)
 A strong desire for the primary and/or secondary sex
characteristics that match one’s experienced gender
APA, 2013
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Strong incongruence between experienced/expressed
gender and primary and/or secondary sex characteristics
Strong desire to be rid of one’s primary and/or secondary
sex characteristics
Strong desire to be of other gender
Strong conviction that one has the typical feelings and
reactions of the other gender (or some alternative gender
different from one’s assigned gender)
A strong desire to be treated as the other gender
APA, 2013
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How we refer to our clients
Which pronoun would you like me to use? (e.g. he, she)
Use the (WPATH) model
Cultural Sensitivity and Cultural Competence is important
for providers administering services to various groups;
programming needs to be sensitive to varying populations
with diverse issues
Considerations:
 Age
 MTF or FTM
 Race
 Religion/Spirituality
 Geographic Region
 SES
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1. Increase inclusion and participation of GBTQ youth of color in school-based educational and
after school programs such as athletics, academic clubs, and college preparation courses.
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2. Develop specialized services for subgroups of GBTQ youth, including transgender youth,
closeted or questioning youth, and bisexual youth. These subgroups of youth often have distinct
needs relative to gay male youth, such as the unique healthcare needs of transgender youth, or
are disconnected from services, such as youth who are reluctant to disclose or who are unsure
of their sexual orientation.
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3. Create, expand, or enhance (as appropriate) availability of needed services including, mental
health services, mentorship programs, life skills training, vocational and workforce training, and
health education programs that cater to the special needs of GBTQ youth of color.
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4. Connect GBTQ youth with adult LGBT role models to facilitate mentorship relationships not
always available to youth. This is particularly significant with regard to modeling diversity within
an organization. Role models are also helpful for parents and families of GBTQ youth of color as
family members see successful LGBT people of color and can promote family acceptance. 5.
Widely publicize resources through youth networks and creative marketing strategies so that
more GBTQ youth (and their families) are aware of the services available to them. Publicizing
effort should target youth themselves, their families, and non-LGBT organizations so that they
can make appropriate referrals to GBTQ youth they see. To design effective advertising
campaigns, agencies ought to tailor messages to subgroups of GBTQ youth
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Rates are likely to be underestimated given fear to self-identify,
research in infancy with this population; high rates of use shown
in a meta-analysis by Herbst et al., in 2008.
Garofalo, et al. (2008) found approximately 25% of transgender
women in U.S. convenience sample studies report nonmarijuana
illicit drug use, such as cocaine, crack, amphetamine, or heroin
HIV has also been reported at a higher incidence among this
population (Reisner, 2014; Herbst et al., 2008; SAMHSA, 2012)
Disproportionally higher rates of smoking and tobacco use has
been consistently documented (Wisneski, 2011; Conron et al.,
2012)
“Emerging evidence demonstrates among transgender persons,
there are higher rates of non-medical use of prescription drugs
among those experiencing discrimination based on transgender
identity” (Benotsch et al., 2013)
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Findings from the NY Transgender Project (Nuttbrock et al.,
2009) yielded prevalence rates of self-reported substance
use during the prior 6 months as 60,4% for heavy alcohol
use, 40% for THC (marijuana), 21.7% for cocaine (crack or
powder), 3.9% for stimulants, and 3.5% for opiates.
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Flentije (2014) found transgender women to endorse
significantly greater primary methamphetamine use
Issues in treatment include:
Societal and Internalized transphobia
Violence
Discrimination
Family problems
Isolation
Lack of Educational and Job Opportunities
Access to health care
Low Self-Esteem
(A Provider’s Introduction to Substance Abuse Treatment for
Lesbian, Gay, Bisexual and Transgender Individuals, 2012)
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https://www.youtube.com/watch?v=LcJ0CBSPpLY
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What your agency may want to include in biospychosocial
assessments
E.g. surgeries
Transition/hormone replacements
Identified Gender (not only male/female)
Evaluate relationship between substance use and issues
related to gender and social acceptance
Assessment of family acceptance
Suicidality; including history of self-injury
Bullying
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Clients may need assistance in education regarding the
effects of treatment; physical and emotional (changes in
mood)
Education regarding the interaction of hormone therapy and
substance use/abuse
Risks of “black market” hormones, such as testosterone
Triggers of hormonal injection to addiction: Teach coping
strategies
Assist with compliance with medical regimens
SAMHSA (2012). A provider’s Introduction to substance abuse
treatment for lesbian, gay, bisexual, and transgender individuals.
World Professional Association for Transgender Health (WPATH).
(2012). Standards of Care for the Health of Transsexual,
Transgender, and Gender Nonconforming People (7th ed.).
International Journal of Transgenderism, 13(4), 165–232.
doi:10.1080/15532739.2011.700873
American Psychological Association. (2008). Report of the APA task
force on gender identity and gender violence. Washington, DC:
Author.
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Support
Stages of Gender Identity
Coming out: Substance Use and Recovery interact with experience of sexual identity
Suicide
Laws
Awareness of staff and clients
Facilities (bathrooms)
Medical Issues
Increase likelihood co-occurring disorders (past traumas, PTSD, substances, Mood
Disorders)
Community resources are minimal
Correctional Settings:
 Housing
 Risk Management
 Mental Health Units
 Medical Issues
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“Use the proper pronouns based on their self-identity when talking
to/about transgender individuals.
• Get clinical supervision if you have issues or feelings about working
with transgender individuals.
• Allow transgender clients to continue the use of hormones when they
are prescribed. Advocate that the transgender client using “street”
hormones get immediate medical care and legally pre scribed
hormones.
• Require training on transgender issues for all staff.
• Find out the sexual orientation of all clients.
• Allow transgender clients to use bathrooms and showers based on
their gender self-identity and gender role.
• Require all clients and staff to create and maintain a safe
environment for all transgender clients. Post a nondiscrimination policy
in the waiting room that explicitly includes sexual orientation and
gender identity.”
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“Don’t call someone who identifies himself as a female he or him
or call someone who identifies herself as male she or her.
• Don’t project your transphobia onto the transgender client or
share transphobic comments with other staff or clients.
• Never make the transgender client choose between hormones
and treatment and recovery.
• Don’t make the transgender client educate the staff.
• Don’t assume transgender women or men are gay.
• Don’t make transgender individuals living as females use male
facilities or transgender individuals living as males use female
facilities.
• Never allow staff or clients to make transphobic comments or
put transgender clients at risk for physical or sexual abuse or
harassment.”
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Florida –Bathrooms
Lift of Military Ban
Legal Documents
Charting (look at WPATH)
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Kyler’s Poem
My mirror does not define me:
Not the stranger that looks back at me
Not the smooth face that belongs to someone else
Not the eyes that gleam with sadness
When I look for him and can only see her.
My body does not define me:
Not the slim shoulders that will not change
Not the hips that give me away
Not the chest I can’t stand to look at
When I look for him and can only see her.
My clothes do not define me:
Not the shirt and the jeans
That would look so perfect on him
But that I know would never fit me
When I look for him and can only find her.
And I’ve been looking for him for years,
But I seem to grow farther away from him
With each passing day.
He’s trapped inside this body,
Wrapped in society’s chains
That keep him from escaping.
But one day I will break those chains.
One day I will set him free.
And I’ll finally look in the mirror
And see meThe boy I was always meant to be.
- Kyler Prescott
July 7, 2000 – May 18, 2015
nydailynews..com
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American
Psychiatric Publishing.
American Psychological Association. (2008). Report of the APA task force on gender identity and gender violence. Washington, DC:
Author.
Conron, K. J., Scott, G., Stowell, G. S., & Landers, S. J. (2012). Transgender health in Massachusetts: results from a household
probability sample of adults. American Journal of Public Health, 102(1), 118-122. doi:10.2105/AJPH.2011.300315
Lyons, T., Shannon, K., Pierre, L., Small, W., Krusi, A., & Kerr, T. (2015). A qualitative study of transgender individuals’ experiences in
residential addiction treatment settings: Stigma and inclusivity. Substance Abuse Treatment, Prevention, and Policy, 10(17), 2-6.
doi:10.1186/s13011-015-0015-4.
Garofalo, R. Deleon, J., Osmer, E., Doll, M., & Haper, G.W (2006). Overlooked, misunderstood and at-risk of ethnic minority male-tofemale transgender youth. Journal of Adolescent Health, 38, 230-236. doi:10.1016/j.jadohealth.2005.03.023.
Herbst, J. H., Jacobs, E. D., Finlayson, T. J., McKleroy, V. S., Neumann, M. S., & Crepaz, N. (2008). Estimating HIV prevalence and risk
behaviors of transgender persons in the United States: a systematic review. AIDS and Behavior, 12(1), 1-17. doi:10.1007/s104610079299-3.
Nuttbrock, L. (2012). Culturally competent substance abuse treatment with transgender persons. Journal of Addictive Disease, 31,
236-241. doi:10.1080/105550887.2012.694600.
Reisner, S. L., Gamarel, K. E., Nemoto, T., & Operario, D. (2014). Dyadic effects of gender minority stressors in substance use behaviors
mong transgender women and their non-transgender male partners. Psychology of Sexual Orientation and Gender Diversity, 1(1), 6371. doi:10.1037/0000013.
SAMHSA (2012). A provider’s Introduction to substance abuse treatment for lesbian, gay, bisexual, and transgender individuals.
Rockville, MD: U.S. Government Printing Office.
Stotzer, R., Silverschanz, P, & Wilson, A. (2013). Gender identity and social service: Barriers to care. Journal of Social Service Research,
39, 63-77. doi:10.1080/01488376.2011.637858.
Walls, E., & Wisneski, H. (2011). Evaluation of smoking cessation classes for the lesbian, gay, bisexual, and transgender community.
Journal of Social Service Research, 37, 99-11. doi: 10.1080/01488376.2011.5245531
World Professional Association for Transgender Health (WPATH). (2012). Standards of Care for the Health of Transsexual, Transgender,
and Gender Nonconforming People (7th ed.). International Journal of Transgenderism, 13(4), 165–232.
doi:10.1080/15532739.2011.700873